[Noah930]

You're asking two separate questions about cubital tunnel syndrome.

First of all, is it time to have surgery? What are your symptoms? How bad are they? Episodic numbness in the pinky (small finger) and ring finger? Or constant? Pain at the elbow? Hand weakness or muscle atrophy? Or do you actually have a nerve that is snapping/subluxing (rare)?

What treatments have you tried so far? Therapy? Cortisone injection? Behavioral modification?

If you've settled on surgery, there are maybe 4 different ways to do it. The first way is in-situ decompression. The nerve is held in place by connective tissue between the bony medial epicondyle and bony olecranon. That connective tissue is too tight, thereby pinching the nerve. (But God/Darwin put it there for a reason, too.) So in in-situ decompression, the connective tissue is cut. Released. That's it. It takes the compressive pressure of that connective tissue off of the nerve. That's the least invasive open technique of surgery.

The second method of open surgery is in-situ decompression with a subcutaneous anterior ulnar nerve transposition. Do the above in-site decompression. Then, take the nerve, and move it from its natural position "behind" (posterior to) the medial epicondyle, and transpose it (move it) to a new location alongside the medial aspect of the elbow. Transpose the nerve anterior to the bony medial epicondyle. Obviously that's a little more invasive, as now you're moving the ulnar nerve from its natural position. The theory is that anterior transposition also takes some traction tension off of the nerve. When you flex (bend) your elbow, the nerve has to travel the "long way" around the elbow's axis of rotation. Thus, the nerve gets stretched a little bit. Like a rope around a pulley. (Or think of the path an outer wheel travels compared to an inner wheel when you drive a car around a corner.) Maybe that contributes to its irritation in cubital tunnel syndrome. So if we can relieve traction on the nerve, perhaps that helps it recover. Take that rope off the pulley, to give it slack. The theoretical problem with moving the nerve is that the dissection of the nerve from its native bed may damage its blood supply, thereby causing the nerve to die. Maybe this is one of those textbook warnings, as I haven't seen/heard of this ever happening before to anyone I know ... but it's always in the back of my mind when performing this surgery.

The third open method is a submuscular transposition. Do the same as above: release the nerve, move it from its native bed, and transpose it. But instead of just transposing the nerve from the "back" of the elbow joint to the "side" of the elbow joint, you also bury it underneath the common flexor tendon origin--the tendon and muscle that comes off of the medial epicondyle. That also allows for padding the nerve, so it's not just underneath the skin as in an anterior subcutaneous transposition. This surgery requires detaching the big tendon/muscle off the bony medial epicondyle, burying the nerve, and then reattaching the tendon/muscle unit back to the bone. This is the most invasive open surgery technique. This is also the surgery that is usually done (by just about everyone) if a revision surgery is needed. If you ever have to have a second go at it, almost every surgeon will use this technique because it is the most definitive. So some surgeons argue (whether you agree with this logic or not) that why wait for a revision to do the most definitive surgery? Just do it from the get-go and be done with it.

More invasive usually means takes longer surgical time, greater chance of complication, more painful (post-op), and longer recovery timeframe. It doesn't guarantee these things, but these are trends in general.

Looking at the literature, for a first time surgery, all three techniques have similar long term outcomes. So there's no one way that is clearly better than the rest. I wouldn't pick a surgeon based upon which technique he/she uses, for example. I'd pick the surgeon, and then go with whichever way he/she practices. In general, the surgery is usually not a particularly painful one. There may be some medial ("inside" side--the side that brushes up against your body when you walk) elbow pain for a month or two after the surgery, and it may take 6-8 months for all the residual pain to go away, but it's usually not a big enough deal to keep you from living a normal lifestyle after that initial 1-2 months post-op.

The final way of cubital tunnel release is a newer method: endoscopic. But it's just another way of doing the in-situ decompression technique. This is where a camera is used. A small 1- or 2-inch incision is made at the elbow, and the crux of the surgery is done via a blade mounted on the end of a video camera. This really is a newer technique that really has only come into play over the past 5-10 years. Probably closer to 5 than to 10. Each company that makes a kit/system is a little bit different than the next (for intellectual property patents), but the idea is similar. Small incision, and use a canula to introduce a camera to watch a blade cut the connective tissue (and not the nerve!). Smaller incision means less pain and quicker recovery, as the theory goes. But the concern is always that small incision means poorer visibility and greater potential for nerve injury.